Introduction to History Taking in Internal Medicine
Introduction
The medical history is the foundation of internal medicine. The answer to the patient’s problem is in
the history 90% of the time! The other 10% of the time, you will need to use investigations to help
you figure the answer out.
Identification
Start your presentation with the patient’s name, age, sex, home and referral status. Fore example:
Luke Smart, 32 year old male, self referral to Bugando Medical Centre.
Chief Complaint (CC)
This is the main reason the patient came to the hospital. Ask the patient, “Why did you come to the
hospital?” It is normally, one complaint, but can contain up to two or even three main complaints.
State the duration of the complaint. For example: disturbance in breathing for two weeks.
History of Present Illness (HPI)
This should be a story about how the symptoms developed. Use the patient’s own words as much as
possible. Avoid medical terminology (like the word “angina”) unless the patient actually uses that
word. Usually a patient will say “chest pain” instead of “angina.” Begin with the earliest symptoms
related to the chief complaint and proceed chronologically. For example: “The patient described
chest pain when walking up a hill four weeks ago. This resolved with rest and recurred with activity.
Eventually the chest pain subsided and the patient began to experience shortness of breath when
walking short distances. One week ago, the patient began to notice that they were short of breath
when lying flat and began having swelling in his legs.
Review of Other Systems (ROS)
Review the systems that are not involved in the chief complaint. The system that is involved in the
chief complaint should be reviewed within the HPI. Usually the ROS is done from head to toe
(neurological, cardiovascular, pulmonary, gastroenterology, renal, genitourinary, and
musculoskeletal). Review every system every time you take a history, but when you present the
patient, only mention the ones that are important negatives and positives related to the chief
complaint. For example, if the patient has abdominal pain, then the gastroenterology system will be
reviewed in the HPI, and the cardiovascular, renal, and genitourinary systems ought to be specifically
mentioned in the ROS. If you do not know which systems are relevant to the HPI, it is always better
to include more information than less.
Past Medical/Surgical History (PMSHx)
This includes past admissions, chronic medical problems, medications, allergies, immunizations,
prior surgeries, prior blood transfusions, and for women gynecological history. Any part of the PMHx
related to the CC should also be mentioned in the HPI. For example, if the patient presents with
chest pain that started one month ago and was admitted two weeks ago for this complaint, then it
should be included in the HPI. One way to figure out if they have any chronic medical problems is to
ask if they have ever gone to the clinic or if they are on any medication. For some past medical
problems it is important to include more than just a diagnosis. For example, if the patient has IDS,
then you want to include their baseline CD4 count, whether they are on ART, and if so how long. For
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the allergy section, ask specifically what kind of reaction they had. If they don’t remember what kind
of medicine they had an allergy to, you can always try to figure out what medication it is by asking
them why they were taking it. You can also ask if it was a pill or an intravenous medication. For
women remember to include the last menstrual period
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